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Pediatric Orthopedics Symptoms Differential Diagnosis Supplementary Assessment and Treatment 1st Edition Jan Douwes Visser
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Jan Douwes Visser
Pediatric
Orthopedics
Symptoms, Differential
Diagnosis, Supplementary
Assessment and Treatment
123
Pediatric Orthopedics
Jan Douwes Visser
Pediatric Orthopedics
Symptoms, Differential Diagnosis,
Supplementary Assessment
and Treatment
Jan Douwes Visser
Groningen
The Netherlands
Word processing: Hendrika Schotanus and Yvonne Werink. Translation: Prof. Peter
H. Robinson, MD., Ph.D. Drawings: Douwe Buiter
v
Acknowledgments
Advisory Board
Minne Heeg, M.D., Ph.D.
Pediatric orthopedic surgeon
Wilhelmina Hospital Assen, The Netherlands
Sjoerd K. Bulstra, M.D., Ph.D.
Professor and chairman Department of Orthopedic Surgery
University Medical Center Groningen, The Netherlands
Peter H. Robinson, M.D., Ph.D.
Emeritus Professor of Plastic, Hand and Reconstructive Surgery
University Medical Center Groningen, The Netherlands
vii
Abbreviations
ix
Contents
xi
xii Contents
Chest Wall Deformity Fusion disorder of the sternum Partial fusion dis-
orders of the cranial area are the most common. In
Complaint: there is a deformity of the chest the distal area they are very rare. It is also possible
wall. that the sternum is split along the entire length (total
sternal fissure). This abnormality is accompanied by
Assessment: deformity of the chest wall.
cardiac anomalies and/or defects in the diaphragm.
Differential diagnosis:
pectus carinatum (pigeon breast) Absent ribs In this abnormality several ribs are
pectus excavatum (funnel chest) usually absent on one side of the chest wall.
fusion disorder of the sternum There may also be sternal and vertebral abnor-
absent ribs malities such as hemivertebrae and block verte-
Poland syndrome brae. As a result there is a flail thorax, which can
lead to a shortness of breath.
Explanatory note: pectus carinatum. The
sternum and the adjoining cartilage and bone
Poland syndrome In Poland syndrome1 there is a
are anteriorly prominent (Fig. 1.1). The abnor-
unilateral absence of the pectoralis minor muscle
mality is most noticeable in the first year of
and the sternal part of the pectoralis major muscle
life, but can also develop during puberty
(Fig. 1.4). Males are affected in 70 % of cases. It is
(Fig. 1.2). As a rule, pigeon breast is only a
generally combined with abnormalities of the hand
cosmetic issue. Respiratory difficulties may
on the same side, such as small hands (hypoplasia)
occur when the sternum shifts strongly for-
with absent fingers, webbed fingers (syndactyly)
ward, causing the thorax to be in a continuous
and/or shortened fingers (brachydactyly). The com-
inspiratory position.
bination of hypoplasia of the hand, syndactyly and
brachydactyly is sometimes called symbrachydac-
Pectus excavatum There is an indentation on
tyly. There may also be absence of the forearm flexor
the front side of the chest. The deepest area
muscles and the entire arm may be under-developed.
lies at the level of the distal part of sternum
Associated anomalies may be the Klippel-Feil
and the xiphoid process (Fig. 1.3). The abnor-
syndrome1 (short neck), Möbius syndrome1 (paraly-
mality is usually present at birth, but can also
sis of the facial muscles), a Sprengel deformity
develop later. A funnel chest seldom causes
(elevated shoulder blade) and pectus excavatum.
physical complaints, the issue tends to be only
cosmetic. The abnormality is common in Marfan
syndrome. 1
See Appendix.
a b
Fig. 1.1 (a) Boy, about 5 years old, with a pectus carinatum (pigeon breast). (b) After treatment with a trunk orthosis
with a pressure pad
Fig. 1.2 A pectus carinatum (pigeon breast) can also Fig. 1.3 Pectus excavatum (funnel chest)
develop during puberty
a b
Fig. 1.5 (a) Starting at the first year of age, a pectus carinatum (pigeon breast) can be treated using a trunk orthosis
with a pressure pad for the prominent thoracic area. (b) The pressure pad on the inner side of the trunk orthosis
a b
is spread between the mastoid process and the in adults are possible as a result of compres-
acromion on both sides. sion of the myelum or of the exiting spinal
nerves.
Diagnosis: Klippel-Feil syndrome1 (con- Supplementary assessment: X-rays as well
genital brevicollis) as a CT-scan and a MRI of the cervical and
Explanatory note: Klippel-Feil syndrome. thoracic spines.
The clinical picture was described by the Primary care treatment: if the patient has no
French physicians Klippel and Feil in 1911 pain or neurological symptoms there will be
as “l’homme sans cou” (man without a neck). a wait-and-see policy. If there is pain, it is
The short neck is caused by vertebrae that advisable to limit the activities and a cervical
have fused together. There may also be a collar can be prescribed.
unilateral unsegmented bony connection,
When to refer: in the early phase to the
hemivertebrae, absence of the posterior ele-
pediatrician before detecting any other
ments (arches and spinal processes), a basilar
anomalies. Referral should be made to the
impression, an occipitoatlantal synostosis, an
orthopedic surgeon for additional anomalies
atlanto-axial subluxation and a hypoplasia of
such as muscular torticollis and scoliosis,
the dens. In 20 % of cases the abnormality is
and to the neurosurgeon if neurological
accompanied by a torticollis, in 60 % there is
complications occur at an older age.
a kyphoscoliosis at the thoracic level caused
by the hemivertebrae and unilateral and Secondary care treatment: Klippel-Feil
unsegmented bony connections. In 30 % of syndrome. A torticollis based on a short-
cases there is an elevated posture and under- ened sternocleidomastoid muscle can
development of the shoulder blade, known as be treated by dividing or lengthening
a Sprengel deformity. In about 25 % of cases the muscle. Neurological symptoms are
there are cardiac and renal abnormalities, and caused mostly by an atlantoaxial sublux-
in 30 % deafness. Neurological complications ation, a basilar impression or a congenital
occipitoatlantal synostosis (for treatment,
1
See Appendix. see pp. 15, 18, 19).
Neck Deformity 9
Wry Neck
a b c
Fig. 2.4 (a) The sternocleidomastoid muscle has a be divided. (b, c): In this case the sternocleidomastoid
sternal and a clavicular origin. The shared muscle belly muscle is divided at the mastoid process and occiput.
inserts into the mastoid process and occiput just behind The origins of the clavicular and sternal head are length-
the ear. The sternocleidomastoid muscle can operatively ened with a Z-plasty (Redrawn from: Ferkel RD, Westin
be lengthened or divided at the level of the clavicle and GW, Dawson EG, Oppenheim WL. Muscular torticollis.
sternum. If there is a recurrence the insertion at the level A modified surgical approach. J Bone Joint Surg Am.
of the mastoid process and occiput may also have to 1983;65-A:894–900)
a bnormality is later on identified on the basis of Juvenile muscular torticollis Sometimes a mus-
a contracture of one or both heads of the sterno- cular torticollis appears at childhood. In that case
cleidomastoid muscle. there is a contracture of both heads of the sterno-
The sternocleidomastoid muscle has a sternal cleidomastoid muscle. This condition does not
and a clavicular origin. The joint muscle belly recover spontaneously.
inserts into the mastoid process and occiput just
behind the ear (Fig. 2.4). The cause of the swell- Osseous torticollis Due to the presence of a
ing in the sternocleidomastoid muscle is unclear. hemivertebra (half vertebra) or one or several
It used to be assumed that during a difficult birth asymmetric nonsegmented bony connections, a
(breech presentation or forceps delivery) there wry neck can be present. The patient has Klippel-
was bleeding into this muscle, followed by fibro- Feil syndrome2 if the neck is also too short.
sis of the hematoma. However, blood in the swell- Goldenhar syndrome or oculoauriculovertebral
ing has never been shown. It is now assumed that dysplasia is a special form of osseous torticol-
the fibrous tissue is already present before birth. lis in which in addition to abnormal vertebrae
there are also eye and ear abnormalities such as
Spontaneous recovery of the torticollis occurs epibulbar dermoid cysts and preauricular skin
during the first year of life in 90 % of cases. If the anomalies.
abnormality persists, the face and the skull will
also become deformed, with a flattening of the Ocular torticollis This anomaly is present from
skull and the face on the side of the contracture birth, but is often only noticed around the age of
(plagiocephaly). A developmental dysplasia of 9 months, after the child has achieved sitting bal-
the hip is found in 20 % of children with an infan- ance. Paresis of the extraocular muscles, gener-
tile muscular torticollis. If there is no contracture ally the superior oblique muscle, causes crossed
of the sternocleidomastoid muscle, the underly- and double vision when the head is held horizon-
ing causes are a congenital anomaly of the skel-
eton or an ocular abnormality. 2
See Appendix.
Neck Deformity 11
tally. The child must hold his head slanted in the spontaneous recovery. In such cases, the ster-
frontal plane to prevent double vision. nocleidomastoid muscle should be opera-
tively lengthened or divided at the clavicular
Supplementary assessment: radiological
and/or sternal origin (Fig. 2.4). The ideal age
assessment of the cervical spine to reveal or
for operative treatment is in the third year
rule out an osseous torticollis. In infantile
of life. The asymmetry of the face and the
or congenital muscular torticollis an ultra-
skull restores completely after that. Operating
sound of the hips or an anteroposterior
before this age increases the chances of an
X-ray of the pelvis should be made to check
ugly scar and retraction of the skin at the level
for a developmental dysplasia of the hip.
where the sternocleidomastoid muscle has
Primary care treatment: a patient with infantile been lengthened or divided. Even after this
muscular torticollis is usually referred to a pedi- age it is not too late to carry out the correction.
atric physiotherapist up to the age of 18 months. Good cosmetic results can be achieved up to
The parents do stretching exercises under the the age of 12. The sooner the treatment is
supervision of the pediatric physiotherapist. It implemented, the better the ultimate result
is not certain whether these stretching exercises will be with regard to facial symmetry.
influence the natural history. Infantile muscu- Postoperative treatment involves the use
lar torticollis disappears spontaneously around of a neck orthosis day and night for 6 weeks
the first year of life in 90 % of cases. (Fig. 2.5). In the case of a recurrence, in
addition to dividing or lengthening the ori-
When to refer: children with a muscular or
gin at the level of the clavicle and sternum
osseous torticollis should be referred to an
the insertion at the level of the mastoid pro-
orthopedic surgeon when the child is older
cess should also be divided.
than 18 months. If the sternocleido-mastoid
muscle is not shortened and there are no Juvenile muscular torticollis Usually this type
osseous abnormalities the child should be is permanent and requires operative treatment.
referred to an ophthalmologist.
Osseous torticollis Spondylodesis over a trajec-
Secondary care treatment: infantile muscu- tory as short as possible should be carried out.
lar torticollis. If the abnormality is still
present at 1 year of age there is little chance of Ocular torticollis Treatment by an ophthalmologist.
12 2 Neck
Insertion of
apical ligament Transverse
of the dens atlantal ligament
Superior articular
surface
Dens of axis
Atlas
Posterior
3
See Appendix.
Neck Pain 13
Posterior
Os terminale Os odontoideum
< 1 mm
SAC
3 - 4 kg
ADI
When to refer: if there is no throat infec-
Fig. 2.11 Atlantodental index for atlantoaxial instability. tion, no gastroeso-phageal reflux, no disc
Lateral craniometry: the atlantodental index (ADI) is the calcification or juvenile idiopathic arthritis,
distance between the posterior border of the anterior arch or if acute pain has lasted for more than a
of the atlas and the anterior border of the dens. In children
younger than 8 years this distance should be less than week.
4.5 mm and in children older than 8 years it should be less
Secondary care treatment: occipitoatlantal
than 2 mm. Spinal canals with a anteroposterior diameter
(SAC Space Available for Cord) of less than 13 mm have and atlantoaxial subluxation. Most patients
a canal stenosis with an increased risk of spinal cord com- whose symptoms have been present for less
pression (Redrawn from: Copley LA, Dormans than a week can be treated with a soft collar.
JP. Cervical spine disorders in infants and children. J Am
The soft collar is no longer required after the
Acad Orthop Surg. 1998;6:204–14)
symptoms disappear. It is recommended to
treat the subluxation by using traction with
canal with an increased risk of spinal cord
a Glisson sling if the symptoms have been
compression.
present for more than a week, (Fig. 2.12). A
If a discitis is suspected it is prudent to do an
CT-scan should be taken to assess whether
MRI at an early stage in addition to determin-
the subluxation has been corrected. In this
ing the CRP and the ESR and taking blood
case, a follow-up treatment ensues with a
cultures. Disc calcification can be easily rec-
soft collar for 6 weeks. The subluxation
ognized on lateral X-rays of the cervical
must be corrected non-operatively under
spine. In juvenile idiopathic arthritis general-
anaesthetic, followed by immobilization for
ized abnormalities are often present shortly
3 months using a Minerva cast (Fig. 2.13)
before or after the neck problems appear, so
or a halo vest, if correction has not
the diagnosis is not very difficult to make.
been achieved or the traction is poorly
Primary care treatment: start by checking tolerated.
whether there is a throat infection (Grisel In occipitoatlantal subluxations a spondy-
syndrome) or heartburn caused by gastro- lodesis is almost never necessary. If the
esophageal reflux (Sandifer syndrome). symptoms last for more than a month, then
These underlying causes must be treated the chances of successful nonsurgical repo-
first. In addition analgesics and a soft cervi- sitioning is slight and a spondylodesis must
cal collar are given for the causes mentioned be carried out. If the atlantodental index
above. The collar can be removed after dis- (ADI) is between 5 and 10 mm, contact
appearance of the symptoms. If X-rays show sports and diving must be avoided and even
disc calcification this can also be treated a prophylactic C1-C2 spondylodesis should
with analgesics and a soft collar as long as be considered. In the case of an atlantoden-
symptoms are present. The worst complaints tal index of more than 10 mm a C1-C2
will disappear after 7–10 days. NSAID’s can spondylodesis is performed regardless of
be given for juvenile idiopathic arthritis. symptomatology.
16 2 Neck
Table 2.5 Tumors with an increased risk of spinal cord Differential diagnosis:
compression in children
Spinal cord compression cervical kyphosis
Astrocytoma basilar impression
Lymphoma primary type
Neuroblastoma secondary type
Sarcoma (in particular Ewing sarcoma) Arnold-Chiari malformation
From: Conrad EU. Pediatric spine tumors with spinal cord stenosis of the foramen magnum
compromise. J Pediatr Orthop. 1992;12:454–60
congenital occipitoatlantal synostosis
hypoplasia or aplasia of the dens
os odontoideum tumor
cord tumors at the cervical level are usually
accompanied by muscle weakness and coordina- Explanatory note: cervical kyphosis (see p. 8).
tion disorders (Table 2.5). Sometimes they can be
very slow-growing and only cause a stiff or
Basilar impression In a basilar impression the
possible wry neck as the sole symptom at the
dens of the axis lies too high in the foramen mag-
moment of assessment.
num. As a result of this, in nearly 80 % of basilar
impressions there is a short neck and in 70 % of
Supplementary assessment: in addition to
cases a wry neck. Structures in the posterior cra-
X-rays, a CT-scan and MRI of the cervical
nial fossa (cerebellum and brainstem) have too
spine and brain should be carried out.
little space because of the elevated position of the
Primary care treatment: the primary care dens. There are two types of basilar impression:
provider, usually the general practitioner, primary and secondary.
must suspect that a single symptom such as
only a slow onset stiff neck may be a sign of Primary type This is a congenital abnormality
a serious abnormality. and is often associated with other anomalies of the
When to refer: every patient with a slow neck vertebrae such as occipitoatlantal synostosis,
onset stiff neck should be referred. an abnormal dens and the Klippel-Feil syndrome4.
Secondary care treatment: tumor. Treatment Secondary type This type is the result of weaken-
of spinal column and spinal cord tumors must ing of the bony (base of the skull) structures as may
take place in a specialized medical center. be seen in rachitis and osteogenesis imperfecta4. In
The treatment is usually surgical, depending 85 % of basilar impression cases there is a paresis
on the nature of the tumor and/or radiother- and paresthesia of the extremities. There may also
apy and/or chemotherapy may be necessary. be difficulties with swallowing resulting from
compression of the cranial nerves IX, X and XII.
ainful Stiff and Possibly Wry Neck
P
with Neurological Symptoms Arnold-Chiari malformation Arnold-Chiari
malformation is caused by a caudal displacement
Complaint: painful, possibly wry neck accom- of the tonsils of the cerebellum into the foramen
panied by neurological symptoms. magnum. This deformity is accompanied by a
basilar impression in half of all cases. Symptoms
Assessment: the most noticeable are symp- tend to arise between the ages of 10 and 30. In
toms of the neurological deterioration. There addition to neck pain there is often a forced neck
may be a nystagmus, cerebellar ataxia caus- posture, accompanied by cerebellar and v estibular
ing lack of ordered locomotion, swallowing
disorders and symptoms of headache and
dizziness. 4
See Appendix.
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valuable as exhibiting the kind of passion which love showed itself in
Wordsworth. Passion, in the proper meaning of the word—viz., deep, fiery,
intense, and all-embracing feeling, was certainly not Wordsworth’s. His
love was calm, intellectual, and emotional—but it was not passion. All his
love seems to have passed through his head before it touched his heart. And
yet he loved his wife, and lived, as I said before, very happily with her.
Mrs. Wordsworth, however, was a true household woman, and had not
acquired that faculty of walking which Wordsworth and his sister
possessed, in so eminent a degree. In about a year, therefore, after his
marriage—that is, August 14, 1803,—we find Wordsworth parting from his
wife, and making a tour into Scotland, with his sister and Coleridge, taking
Carlisle on the way. When they arrived at Longtown, they found a guide-
post pointing out two roads,—one to Edinburgh, the other to Glasgow. They
took the latter road, and entered Scotland by crossing the river Sark.
Edinburgh was no favourite place with Wordsworth, and for reasons which
are sufficiently obvious. The tourists then passed through Gretna Green to
Annan, leaving the Solway Frith, and the Cumberland hills to their left
hand. On Thursday the 18th August, they went to the churchyard where
Burns is buried; a bookseller accompanied them, of whom Miss
Wordsworth had bought some little books for Johnny, the poet’s first child.
He showed them first the outside of Burns’ house, where he had lived the
last three years of his life, and where he died. It had a mean appearance, and
was in a bye situation, white-washed, and dirty about the doors, as all
Scotch houses are; flowering plants in the windows. They went on to visit
his grave. He lies in a corner of the churchyard, and his second son, Francis
Wallace, is beside him. There was no stone to mark the spot. The greatest
bard that had sung in Britain for some centuries, lay buried there like a dog.
A hundred guineas, however, had been collected to build a monument over
his ashes. “There,” said the bookseller to the visitors, pointing to a pompous
monument, a few yards off, “there lies Mr. John Bushby, a remarkably
clever man; he was an attorney, and hardly ever lost a cause he undertook.
Burns made many a lampoon upon him; and there they rest as you see.”
Yes, indeed, there they rested; and that was the deep, sad moral of the story.
We shall all rest so at last. They then went to Burns’ house. Mrs. Burns was
not at home, but had gone to the sea-shore with her children. They saw the
print of “The Cotter’s Saturday Night,” which Burns mentioned in one of
his letters having received as a present. In the room above the parlour Burns
died, and his son after him; and of all who saw this parlour on this 18th of
August,—Wordsworth and his sister, Coleridge and the poor bookseller—
who survives? “There they rest, as you see.”
The tourists travelled subsequently through the Vale of the Nith, and
crossing the Frith, reached Brownhill, where they slept.
“I cannot take leave of this country,” says Miss Wordsworth, in her
Journal, “without mentioning that we saw the Cumberland mountains
within half a mile of Ellisland (Burns’ house) the last view we had of them.
Drayton has prettily described the connection which the neighbourhood has
with ours, when he makes Skiddaw say—
These lines occurred to William’s memory; and while he and I were talking
of Burns, and the prospect he must have had, perhaps from his own door, of
Skiddaw and his companions, we indulged ourselves in fancying that we
might have been personally known to each other, and he have looked upon
those objects with more pleasure for our sakes. We talked of Coleridge’s
children and family, then at the foot of Skiddaw, and our own new-born
John, a few miles behind it; and the grave of Burns’ son, which we had just
seen, by the side of that of his father; and the stories we had heard at
Dumfries, respecting the dangers which his surviving children were
exposed to, filled us with melancholy concern, which had a kind of
connection with ourselves, and with thoughts, some of which were
afterwards expressed in the following supposed address to the sons of the
ill-fated poet:—
During this Scotch tour the party walked through the vale of the Clyde,
visited Glengyle, the scene of some of Rob Roy’s exploits, Loch Lomond,
Inverary, Glencoe, Kenmore, and the Duke of Athol’s gardens; resting
whilst in this latter place on “the heather seat which Burns was so loth to
quit that moonlight evening when he first went to Blair Castle.” Then they
went to the Pass of Killicranky, respecting which Wordsworth wrote the
following sonnet.
In the year 1803, when this sonnet was written, an invasion was hourly
looked for; and Miss Wordsworth and her brother (for Coleridge had left
them, worried by the “evil chance,” and something worse perhaps at Loch
Lomond) could not but think with some regret of the times when from the
now depopulated Highlands, forty or fifty thousand men might have been
poured down for the defence of the country, under such leaders as the
Marquis of Montrose, or the brave man who had so distinguished himself
upon the ground where they were standing.
The tourists returned by way of Edinburgh, visiting Peebles and Melrose
Abbey. Sir Walter, then Mr. Scott, was, at the time of their visit to the
abbey, travelling as Sheriff of Selkirk to the assizes at Jedburgh. They dined
together at the Melrose Inn. Sir Walter was their guide to the abbey, taking
them into Mr. Riddel’s gardens and orchard, where they had a sweet view of
it through trees, the town being quite excluded. Sir Walter was of course at
home in the history and tradition of these noble ruins, and pointed out to his
visitors many things which would otherwise have escaped their notice.
Beautiful pieces of sculpture in obscure corners, flowers, leaves, and other
ornaments, which being cut in the durable pale red stone of which the abbey
is built, were quite perfect. What destroyed, however, the effect of the
abbey, was the barbarous taste of the good Scotch people who had built an
ugly, damp charnel house within the ruins, which they called a church!
Quitting Melrose, they crossed the Teviot by a stone bridge, and visited
Jedburgh. It rained all the way, and they arrived at the inn just before the
judges were expected out of court to dinner, very wet and cold. There was
no private room but the judges’ sitting-room, and they had to get private
lodgings in the town. Scott sat with them an hour in the evening, and
repeated a part of his “Lay of the Last Minstrel.” Their landlady was a very
remarkable woman; and Wordsworth wrote some verses expressive of the
feelings with which she inspired him. Here is the burden.
This Scottish tour was a little episode in the quiet history of the poet’s
residence at Grasmere. The truth is, that Wordsworth could not at this time
rest long, even in his beautiful Grasmere, without the excitement of
pedestrian travel and adventure. It was likewise a part of his education as a
poet; the knowledge which he thus acquired of men, manners, and scenery.
He had devoted himself to poetry; and every thing that tended to feed the
divine faculty, he grasped at with an avidity equally as intense as that with
which your mere canine man grasps at food for his perishing body. Nothing
comes amiss to him; high and low, great and small; from the daffodil to
Skiddaw—from Skiddaw to heaven and its hosts of glorious stars,—all are
seized by this omnivorous poet, fused in his mind, and reproduced by him
in song. His limited means are no barrier to his wanderings; he and his
sister can live upon black bread and water, so far as rations are concerned;
but setting aside the necessity of the case, this economy is for a sacred
purpose,—viz.:—that they may enjoy the communion of Nature, and
partake of her spiritual banquets. The gods, however, had determined to pet
Wordsworth, and recompense him for his religious devotion to their doings
through early life; and, to say nothing of the bequest of Raisley Calvert, the
second Lord Lonsdale, just as the poet needed a wife, and larger means,
paid the debt which his predecessor owed to Wordsworth’s father,
amounting to £1,800, as the share of each member of the family. This was a
most fortunate circumstance to Wordsworth and his sister; though it
mattered little to the rest, because they were well appointed in life. De
Quincy says that, a regular succession of similar, but superior, God-sends
fell upon Wordsworth, to enable him to sustain his expenditure duly, as it
grew with the growing claims upon his purse; and after enumerating the
three items of “good luck,” mentioned above, he adds:—and “fourthly,
some worthy uncle of Mrs. Wordsworth’s was pleased to betake himself to
a better world; leaving to various nieces, and especially to Mrs. W.,
something or other, I forget what, but it was expressed by thousands of
pounds. At this moment Wordsworth’s family had begun to increase; and
the worthy old uncle, like every body else in Wordsworth’s case (I wish I
could say the same in my own), finding his property clearly ‘wanted,’ and
as people would tell him ‘bespoke,’ felt how very indelicate it would look
for him to stay any longer, and so he moved off. But Wordsworth’s family,
and the wants of that family, still continued to increase; and the next person,
being the fifth, who stood in the way, and must, therefore, have considered
himself rapidly growing into a nuisance, was the Stamp-Distributor for the
county of Westmorland. About March, 1814, I think it was, that this very
comfortable situation was vacated. Probably it took a month for the news to
reach him; because in April, and not before, feeling that he had received a
proper notice to quit, he, good man—this Stamp-Distributor—like all the
rest, distributed himself and his offices into two different places,—the latter
falling of course into the hands of Wordsworth.
“This office, which it was Wordsworth’s pleasure to speak of as a little
one, yielded, I believe, somewhere about £500 a year. Gradually even that,
with all former sources of income, became insufficient; which ought not to
surprise anybody; for a son at Oxford, as a gentleman-commoner, could
spend at least £300 per annum; and there were other children. Still it is
wrong to say, that it had become insufficient; as usual it had not come to
that; but, on the first symptoms arising that it would soon come to that,
somebody, of course, had notice to consider himself a sort of nuisance elect,
—and in this case it was the Distributor of Stamps for the county of
Cumberland.” And in this strain of good-humoured banter—stimulated no
doubt by his own precarious circumstances, in a measure, circumstances
which ought not in his case to be precarious,—De Quincy relates how
another £400 a year was added to the poet’s income from the increase of his
district as Stamp-Distributor.
In 1842, since De Quincy wrote the above, Wordsworth resigned this
office, and it was bestowed upon his son,—whilst he (the poet,) was put
down upon the Civil-list for £300 a year, and finally made Poet Laureate.
To return, however, to the more even tenor of these Memoirs:—A
circumstance occurred in the year 1803, shortly after the Scottish tour,
which will further illustrate the “good luck” of Wordsworth, although in this
instance he did not avail himself of it. Sir George Beaumont, the painter,
out of pure sympathy with the poet,—and before he had seen or written to
him,—purchased a beautiful little estate at Applethwaite, near Keswick, and
presented it to him, in order that he (Wordsworth) and Coleridge, who was
then residing at Greta Hall, might have the pleasure of a nearer and more
permanent intercourse. A fragment of Sir George’s letter (good Sir George,
who could recognise genius, and was noble and generous enough to prove
his recognition in a most practical form) is printed in Dr. Wordsworth’s
“Memoirs,” and it shews what a fine heart he had, God bless him! It is
dated October 24, 1803, and runs thus:—
“I had a most ardent desire to bring you and Coleridge together. I
thought with pleasure on the increase of enjoyment you would receive from
the beauties of Nature, by being able to communicate more frequently your
sensations to each other, and that this would be the means of contributing to
the pleasure and improvement of the world, by stimulating you both to
poetic exertions.” The benevolent project of this excellent baronet was
defeated, partly because Coleridge soon after left Greta Hall for a warmer
climate, being impelled to this course by ill health, and partly from private
considerations respecting Wordsworth and his family, which, however, do
not transpire in the “Memoirs.” A curious fact in connection with this gift
of Sir George is, that Wordsworth neglected to thank the donor, or to take
the slightest notice of it, for eight weeks after the writings were placed in
his hands. In a letter addressed to the baronet, dated Grasmere, October
14th, 1803, Wordsworth apologises for this apparent neglect, and attributes
it partly to the overpowering feelings with which the gift inspired him, and
partly to a nervous dread of writing, and a fear lest he should acknowledge
the honour that had been done him in an unworthy manner. “This feeling,”
he says, “was indeed so very strong in me, as to make me look upon the act
of writing to you, not as the work of a moment, but as a thing not to be
done, but in my best, my purest, my happiest moments.” Thus strangely
began one of the few friendships which Wordsworth cultivated with men,
and one which lasted through the life of the noble-hearted baronet, who, in
dying, in the year 1827 (on the 7th of February), left Wordsworth an
annuity of £100 to defray the expenses of an annual tour. (Another instance
of the poet’s “good luck!”) It is right to add, that Wordsworth was deeply
affected by his friend’s death, and that he has left, in his “Elegiac Musings,”
some noble lines to his memory.
Amongst the occasional visitors at Grasmere between the years 1800 and
1804, was Captain John Wordsworth, the poet’s second brother, who was
eventually lost in the Abergaveny East Indiaman, on the 5th of February,
1804. His brother was a man of fine taste and discernment, and prophesied
in various letters and at various times, the ultimate success of Wordsworth’s
poetry. Wordsworth felt severely the untimely death of his brother, whom
he loved with that devoted family fondness, which was characteristic of
him. Writing to Sir George Beaumont upon this event, he says: “February
11th, 1808. This calamitous news we received at two o’clock to-day; and I
write to you from a house of mourning. My poor sister, and my wife, who
loved him almost as we did (for he was one of the most amiable of men) are
in miserable affliction, which I do all in my power to alleviate; but, Heaven
knows, I want consolation myself. I can say nothing higher of my ever dear
brother than that he was worthy of his sister, who is now weeping beside
me, and of the friendship of Coleridge; meek, affectionate, silently
enthusiastic, loving all quiet things, and a poet in everything but words.”
The lyre of the poet sounded his praises in three poems. The first is entitled
“Elegiac Stanzas suggested by a picture of Peel Castle in a storm, painted
by Sir George Beaumont.” The next is “To a Daisy,” which suggests his
brother’s love of quiet and peaceful things, and closes with the tragedy of
his death, and the discovery and final burial of the body in the country
churchyard of Wythe, a village near Weymouth.
he concludes, returning thus finely to the simple flower which suggested the
melancholy train of thought that runs through the poem. The third of these
sad lyrical verses refers to the scene where the poet bade his brother
farewell, on the mountains from Grasmere to Patterdale. The verses upon
the “Picture of Peel Castle,” is the best of all these pieces; and as a fitting
conclusion to this brief memorial of the poet’s brother, I will transcribe it.
all fantastic, all as unreal and shadowy as the moon-light which created
them; whilst at every angle of the road, broad gleams came upwards of
Ullswater, stretching for nine miles northward, but fortunately for its effect,
broken into three watery channels of about equal length, and rarely visible
at once.”
The party, (for Miss Wordsworth and the poet’s children were present on
this occasion,) passed the night in a house called Ewsmere, and in the
morning, leaving his family at this inn, the poet set out, with De Quincy, for
a ramble through the woods of Lowther. These are the woods concerning
which the poet, in a letter to Sir George Beaumont, dated October 17, 1805,
says:—“I believe a more delightful spot is not under the sun. Last summer I
had a charming walk along the river, for which I was indebted to this man
[alluding to a good quaker, who was Lord Lowther’s arbiter elegantiarum,
or master of the grounds, and who was making improvements in them, by
virtue of his office], whose intention is to carry the walk along the river side
till it joins the great road at Lowther Bridge, which you will recollect, just
under Brougham, about a mile from Penrith. This, to my great sorrow! for
the manufactured walk, which was absolutely necessary in many places,
will, in one place, pass through a few hundred yards of forest-ground, and
will there efface the most beautiful specimen of forest pathway ever seen by
human eyes, and which I have paced many an hour when I was a youth,
with one of those I best loved. There is a continued opening between the
trees, a narrow slip of green turf, besprinkled with flowers, chiefly daisies;
and here it is that this pretty path plays its pranks, weaving among the turf
and flowers at its pleasure.” And it was in these woods, just five days after
their introduction to each other, that Wordsworth and De Quincy spent a
whole glorious morning in wild ramblings and in conversation. They dined
together, towards evening, at Emont Bridge, and then walked on to the
house of Captain Wordsworth, at Penrith. The family was absent, and the
poet had business which occupied him all the next day; so De Quincy took
a walk, sauntering along the road, about seventeen miles, to Keswick,
where he enquired for Greta Hall, the residence of the poet Southey. “It
stands out of the town a few hundred yards, upon a little eminence,
overhanging the river Greta.” Mrs. Coleridge and Southey came to the door
to welcome their visitor. “Southey was in person somewhat taller than
Wordsworth being about five feet eleven in height, or a trifle more, whilst
Wordsworth was about five feet ten; and partly from having slenderer
limbs, partly from being more symmetrically formed about the shoulders,
than Wordsworth, he struck me as a better and lighter figure, to the effect of
which his dress contributed; for he wore, pretty constantly, a short jacket
and pantaloons, and had much the air of a Tyrolese mountaineer.... His hair
was black, and yet his complexion was fair; his eyes, I believe, hazel, and
large, but I will not vouch for that fact; his nose aquiline; and he had a
remarkable habit of looking up into the air, as if looking at abstraction. The
expression of his face was that of a very acute, and an aspiring man. So far
it was even noble, as it conveyed a feeling of serene and gentle pride,
habitually familiar with elevating subjects of contemplation. And yet it was
impossible that this pride could have been offensive to anybody, chastened
as it was by the most unaffected modesty; and this modesty made evident
and prominent, by the constant expression of reverence for the great men of
the age (when he happened to esteem them such), and for all the great
patriarchs of our literature. The point in which Southey, however, failed
most in conciliating regard was, in all which related to the external
expression of friendliness. No man could be more sincerely hospitable, no
man more completely disposed to give up, even his time (the possession
which he most valued), to the service of his friends; but, there was an air of
reserve and distance about him—the reserve of a lofty, self-respecting mind,
but, perhaps, a little too freezing,—in his treatment of all persons who were
not amongst the corps of his ancient fireside friends. Still, even towards the
veriest strangers, it is but justice to notice his extreme courtesy, in
sacrificing his literary employments for the day, whatever they might be, to
the duty (for such he made it,) of doing the honors of the lake, and the
adjacent mountains.”
De Quincy says that the habits of the poet Southey were exceedingly
regular, and that all his literary business was conducted upon a systematic
plan. He had his task before breakfast, which, however, must have been an
inconsiderable nothing, for it occupied him only an hour, and rarely that, for
he never rose until eight, and always breakfasted at nine o’clock. He went
to bed precisely at half-past ten, and no sleep short of nine hours, refreshed
him, and enabled him to do his work. He usually dined between five and
six, and his chief labour was done between breakfast and dinner. If he had
visitors, he would sit over his wine, and talk; if not, he retired to his library,
until eight, when he was summoned to tea. At ten he read the London
papers; “and it was perfectly astonishing,” says De Quincy, “to men of less
methodical habits, to find how much he got through of elaborate business,
by his unvarying system of arrangement in the distribution of his time.” All
his letters were answered on the same day that they arrived. Even his poetry
was written by forced efforts, or rather, perhaps, by what De Quincy calls,
“a predetermined rule.” It was by writing prose, however, that Southey got
his living—made “his pot boil,” as he says; and his chief source of regular
income was derived from “The Quarterly Review.” At one time, however,
he received £400 a year for writing the historical part of “The Edinburgh
Annual Register.” This, however, he gave up, because the publisher
proposed to dock £100 from the salary which he had previously paid him.—
Southey, however, could afford to lose this large income, because he had an
annuity which had been settled upon him by his friend, Charles Wynne,
“the brother of Sir Watkin, the great autocrat of Wales.” This annuity,
however, when his friend married, Southey voluntarily gave up; and the
Granvilles, to whom Wynne was related by his marriage, placed Southey on
the civil list, for the sacrifice which he thus made.
Such, then, were the circumstances of Southey at the time of De
Quincy’s visit, and it must be owned that they were very comfortable, for a
poet. Wordsworth came on the day after De Quincy’s arrival, and it was
evident that the two poets were not on the most friendly terms; not that
there was any outward sign of this,—on the contrary, there were all the
exteriors of hospitality and good feeling on both sides; but De Quincy saw
that the spiritual link between them was not complete, but broken; that,
indeed, they did not understand, or fully sympathise with each other. Their
minds and habits were different—I had almost said totally different.
Wordsworth lived on the mountain top, composed there, and drew his
inspiration direct from Nature; Southey lived in his magnificent library, and
was inspired more by books than by natural objects.—Wordsworth’s library
consisted of two or three hundred volumes, mostly torn and dilapidated;
many were odd volumes; they were ill bound—not bound—or put in
boards. Leaves were often wanting, and their place supplied occasionally by
manuscript. These books “occupied a little homely book-case, fixed into
one of two hollow recesses, formed on each side of the fireplace by the
projection of the chimney into the little solitary room up stairs, which he
had already described as his ‘half kitchen, half parlour.’.... Southey’s
collection occupied a separate room—the largest, and every way the most
agreeable in the house.”
Wordsworth’s poetry was subjective—referred chiefly to the inner life of
man; and his dealings with Nature had a special reference to this inner life,
his imagery being the mere vehicle of his thought. Southey’s poetry, on the
contrary, was essentially objective,—a reflex of the outward nature,
heightened by the fiery colouring of his imagination. Wordsworth had a
contempt for books, or, at all events, for most books,—whilst Southey’s
library, as De Quincy says, was his estate. Wordsworth would toss books
about like tennis balls; and to let him into your library, quoth Southey, “is
like letting a bear into a tulip-garden.” De Quincy relates, that Wordsworth
being one morning at breakfast with him at Grasmere, took a handsome
volume of Burke’s from his book-case, and began very leisurely to cut the
leaves with a knife smeared all over with butter. Now tastes and habits such
as those which marked the two poets could not unite them very closely
together; at all events, not at this time; although they were subsequently,
and in later years, upon terms of close intimacy and friendship. Upon the
present occasion, however,—that is to say, during De Quincy’s visit to
Southey—the two poets managed very well together, and the evening was
passed agreeably enough. Next morning they discussed politics, and to the
horror of De Quincy, who was then a young man, and took no interest in the
passing movements of nations, and had always heard the French
Revolution, and its barbaric excesses, stigmatised as infernal,—who was,
moreover a loyal person according to the tradition of his fathers, and a lover
of Mr. Pitt—to his horror, the two poets uttered the most disloyal
sentiments, denouncing all monarchial forms of government, and proposed
to send the royal family to Botany Bay! This proposal, which Southey
immediately threw into extempore verse, was so comical, that the whole
party laughed outright, and outrageously; they then set off towards
Grasmere.
De Quincy speaks in the highest terms of Southey, and in the comparison
which he institutes between Southey and Wordsworth, the latter certainly
sustains loss. I refer the reader to the “Lake Reminiscences” for this, and
other most interesting particulars relating to these poets. Still I cannot bid
adieu to these “Reminiscences,” without using them once more, as
materials for an account of Greta Hall and its occupants.